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Acute flow diverting stents for aneurysmal subarachnoid haemorrhage: a case series
EANS Academy. Rainey M. Sep 27, 2019; 276098; EP01086
Abstract
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Background: Traditional treatments to prevent re-bleeding in aneurysmal subarachnoid haemorrhage (aSAH) include clipping and coiling. However, some aneurysms are difficult to secure by these means. Novel endovascular techniques have been used, and we have reviewed our use of flow diverting stents (FDS) in acute aSAH.
Methods: A retrospective review of patients with aSAH treated in a regional neurosurgical centre from 2009 to 2018 was carried out. Patients treated acutely with FDS had their information gathered from electronic care records, patient notes and radiology systems.
Results: Over ten years, approximately 700 aneurysms were acutely treated for aSAH. 25 were treated acutely with a FDS. 19 of these aneurysms required FDS alone, whilst 6 required FDS with adjuncts (e.g. coils). The decision to proceed with a FDS was multidisciplinary and based on the morphology of the aneurysm: 15 were blisters; 9 were wide necked and shallow; and 1 was wide necked from a dysplastic vessel. The mortality rate was 4% (1/25) due to a re-bleed two weeks following treatment. There was a complication rate of 8% (2/25). These were one asymptomatic fronto-polar infarction and one femoral artery pseudo aneurysm requiring fibrin injection. All surviving patients treated with FDS who had at least 3 months follow up demonstrated complete aneurysm occlusion on angiography. 40% had a ventriculo-peritoneal shunt inserted prior to FDS. As FDS requires dual antiplatelet agents, operative surgery after this carries an increased risk of haemorrhagic complications. A high pressure or programmable valve is used to reduce the risk of subdural haematoma.
Conclusions: FDS appears to be a safe and effective treatment option in patients with aSAH who have morphologically difficult to treat aneurysms. An assessment of hydrocephalus risk based on blood load and ventricular size should be made pre-procedure, with consideration given to placement of a ventriculo-peritoneal shunt before FDS.
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